Leadership and Licensure and the Implementation of Co-Occurring Disorder Treatment Processes in Community Mental Health

Background: More than 38% of clients attending mental health treatment report substance use disorder highlighting the need to implement co-occurring disorder (COD) treatment in mental health settings. The literature on implementation of COD treatment points to a series of program capacity factors that may enable the delivery of this approach. However, there is limited knowledge about the role of two critical factors, Leadership as the initiator of implementation, and the role of licensure as the external pressure to implement. This preliminary study examined the extent to which directorial leadership and program licensure are associated with the delivery of a series of process outcomes representing COD treatment in mental health service organizations.

Methods: Using a random sample of 52 outpatient programs in low-income and racial and ethnic minority communities, this study relied on multivariate regression analyses to examine the association between directorial leadership and licensed status and implementation of evidence-based protocols and practices to address COD. Understanding of findings was enhanced with focus groups conducted at six clinics. Transcribed narratives from focus groups were examined using content analysis software. 

Results: Most programs (81%) reported offering COD treatment but at different degrees. Directorial leadership was positively associated with the delivery of COD treatment (β = 0.253, p = .047, 95% CI = 0.003, 0.502) as well as COD supervision and training (β = 0.358, p = .002, 95% CI = 0.142, 0.575). In contrast, program licensure was negatively associated with COD treatment (β = -0.235, p = .041, 95% CI = -0.460, -0.010) and COD supervision and training (β = -0.195, p = .049, 95% CI = -0.389, -0.001). Findings from the qualitative data suggested that implementation of COD supervision and training relied on key qualities of leadership, namely, the degree of initiative, commitment and supervision associated with the implementation process. However, implementation of COD treatment was inhibited by state regulation that limited financial integration, or programs’ ability to bill for both substance abuse and mental health services.  

Conclusions: Key leadership behaviors play a critical role in responding to organizational implementation of COD in mental health settings serving low income and ethnically diverse populations. In contrast, lack of financial integration limits the impact of licensing regulation on the delivery of COD treatment. Implications for leadership interventions and mental health policy are discussed in the context of health care reform.